Provider Demographics
NPI:1710728183
Name:BOGACHOV, ANASTASIA DIMITRIA
Entity type:Individual
Prefix:
First Name:ANASTASIA
Middle Name:DIMITRIA
Last Name:BOGACHOV
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 N 35TH ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23223-7705
Mailing Address - Country:US
Mailing Address - Phone:206-755-0401
Mailing Address - Fax:
Practice Address - Street 1:2930 W HUNDRED RD
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23831-2126
Practice Address - Country:US
Practice Address - Phone:894-621-7631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-01
Last Update Date:2024-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401418966122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist